Annual Report Of Personal Needs Guardian - County Of Nassau Supreme Court (Page 2 of 4) in pdf

Annual Report Of Personal Needs Guardian - County Of Nassau Supreme Court Page 2

State the age, date of birth and marital status of the Incapacitated Person.

4. State the present residence address and telephone number of the Incapacitated Person. If said

Incapacitated Person does not presently reside at his or her personal home, set forth the name,

address, and telephone number of the facility or place at which said Incapacitated Person resides, and

the name of the chief executive officer of the facility or the person otherwise responsible for the care

of the Incapacitated Person.

State whether there have been any changes in the physical or mental condition of the Incapacitated

Person, and any substantial change in medication.

State the date and place the Incapacitated Person was last seen by a physician and the purpose of that

visit.

Attach a statement by a physician, psychologist, nurse clinician or social worker, or other person who

has evaluated or examined the Incapacitated Person within the three months prior to the filing of this

report, regarding an evaluation of the Incapacitated Person’s condition and the current functional

level of the Incapacitated Person.

State whether the current residential setting is suitable to the current needs of the Incapacitated

Person and why.

Attach a list of any professional medical treatment given to the Incapacitated Person during the

previous year.

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Annual Report Of Personal Needs Guardian - County Of Nassau Supreme Court Page 2